The use of gadolinium for arterial interventions

Elliot B. Sambol, Josien G. Van Der Meer, Ashley Graham, Lee J. Goldstein, John K Karwowski, Rajeev Dayal, Brian Derubertis, K. Craig Kent

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

Background: Gadolinium (Gd) has been traditionally used as a non-nephrotoxic alternative to iodinated contrast for digital subtraction angiography (DSA) in patients with chronic renal insufficiency. However, its use has been questioned on the basis of reports of nephrotoxicity and its recent association with nephrogenic systemic fibrosis (NSF), a potentially lethal complication. Recently available data are conflicting with respect to the true safety profile of intra-arterial Gd. The purpose of this study was to examine the risk of contrast nephropathy and NSF after Gd exposure in a large population of azotemic patients undergoing DSA. Methods: A comprehensive database encompassing data on all patients who underwent DSA between June 2003 and December 2007 at the New York Presbyterian Hospital was retrospectively reviewed. Patients receiving Gd either alone or in combination with iodinated contrast during DSA were identified and further analyzed. Acute renal failure (ARF) was defined as an elevation in serum creatinine (Cr) by >0.5 mg/dL within 48 hours of exposure. Clinical follow-up was conducted through chart reviewing as well as telephonic interviews with patients and their primary care physicians. Results: A total of 153 patients underwent 179 exposures to Gd either alone (33%) or in combination (67%) with iodinated contrast. Mean follow-up duration was 27.1 months. The mean Cr level was 1.94 ± 0.78 mg/dL and 1.96 ± 1.1 mg/dL before and after DSA, respectively. There were 20 (11.2%) instances of ARF. The mean Cr level before DSA was higher in patients who developed ARF versus those in the non-ARF group (2.7 ± 1.1 mg/dL vs. 1.9 ± 0.7 mg/dL, p = 0.004). In the ARF group, 12 patients had a return to baseline renal function, four experienced irreversible renal deterioration, and four needed dialysis (4.5% incidence of irreversible renal failure). There were 19 deaths at the time of this study (12.4%). The highest risk for the development of ARF after Gd exposure occurred in patients with Cr levels of >3.0 mg/dL before DSA and in those receiving >0.4 mmol/kg of Gd. For patients who received iodinated contrast in combination with Gd, there was a trend toward a higher risk for developing ARF as compared with those receiving only Gd. Finally, there were no instances of NSF identified in any of the patients who received intra-arterial Gd. Conclusions: Although Gd has the potential to cause kidney injury similar to iodinated contrast, the risk of irreversible renal failure and the requirement for dialysis is low. Life- or limb-threatening interventions should not be avoided in this patient cohort because of preexisting elevations in Cr. These data should help guide the use of Gd in patients with chronic renal insufficiency.

Original languageEnglish (US)
Pages (from-to)366-376
Number of pages11
JournalAnnals of Vascular Surgery
Volume25
Issue number3
DOIs
StatePublished - Apr 2011
Externally publishedYes

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Gadolinium
Digital Subtraction Angiography
Acute Kidney Injury
Nephrogenic Fibrosing Dermopathy
Creatinine
Renal Insufficiency
Chronic Renal Insufficiency
Kidney
Dialysis
Time and Motion Studies
Primary Care Physicians
Extremities

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery

Cite this

Sambol, E. B., Van Der Meer, J. G., Graham, A., Goldstein, L. J., Karwowski, J. K., Dayal, R., ... Kent, K. C. (2011). The use of gadolinium for arterial interventions. Annals of Vascular Surgery, 25(3), 366-376. https://doi.org/10.1016/j.avsg.2010.09.012

The use of gadolinium for arterial interventions. / Sambol, Elliot B.; Van Der Meer, Josien G.; Graham, Ashley; Goldstein, Lee J.; Karwowski, John K; Dayal, Rajeev; Derubertis, Brian; Kent, K. Craig.

In: Annals of Vascular Surgery, Vol. 25, No. 3, 04.2011, p. 366-376.

Research output: Contribution to journalArticle

Sambol, EB, Van Der Meer, JG, Graham, A, Goldstein, LJ, Karwowski, JK, Dayal, R, Derubertis, B & Kent, KC 2011, 'The use of gadolinium for arterial interventions', Annals of Vascular Surgery, vol. 25, no. 3, pp. 366-376. https://doi.org/10.1016/j.avsg.2010.09.012
Sambol EB, Van Der Meer JG, Graham A, Goldstein LJ, Karwowski JK, Dayal R et al. The use of gadolinium for arterial interventions. Annals of Vascular Surgery. 2011 Apr;25(3):366-376. https://doi.org/10.1016/j.avsg.2010.09.012
Sambol, Elliot B. ; Van Der Meer, Josien G. ; Graham, Ashley ; Goldstein, Lee J. ; Karwowski, John K ; Dayal, Rajeev ; Derubertis, Brian ; Kent, K. Craig. / The use of gadolinium for arterial interventions. In: Annals of Vascular Surgery. 2011 ; Vol. 25, No. 3. pp. 366-376.
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abstract = "Background: Gadolinium (Gd) has been traditionally used as a non-nephrotoxic alternative to iodinated contrast for digital subtraction angiography (DSA) in patients with chronic renal insufficiency. However, its use has been questioned on the basis of reports of nephrotoxicity and its recent association with nephrogenic systemic fibrosis (NSF), a potentially lethal complication. Recently available data are conflicting with respect to the true safety profile of intra-arterial Gd. The purpose of this study was to examine the risk of contrast nephropathy and NSF after Gd exposure in a large population of azotemic patients undergoing DSA. Methods: A comprehensive database encompassing data on all patients who underwent DSA between June 2003 and December 2007 at the New York Presbyterian Hospital was retrospectively reviewed. Patients receiving Gd either alone or in combination with iodinated contrast during DSA were identified and further analyzed. Acute renal failure (ARF) was defined as an elevation in serum creatinine (Cr) by >0.5 mg/dL within 48 hours of exposure. Clinical follow-up was conducted through chart reviewing as well as telephonic interviews with patients and their primary care physicians. Results: A total of 153 patients underwent 179 exposures to Gd either alone (33{\%}) or in combination (67{\%}) with iodinated contrast. Mean follow-up duration was 27.1 months. The mean Cr level was 1.94 ± 0.78 mg/dL and 1.96 ± 1.1 mg/dL before and after DSA, respectively. There were 20 (11.2{\%}) instances of ARF. The mean Cr level before DSA was higher in patients who developed ARF versus those in the non-ARF group (2.7 ± 1.1 mg/dL vs. 1.9 ± 0.7 mg/dL, p = 0.004). In the ARF group, 12 patients had a return to baseline renal function, four experienced irreversible renal deterioration, and four needed dialysis (4.5{\%} incidence of irreversible renal failure). There were 19 deaths at the time of this study (12.4{\%}). The highest risk for the development of ARF after Gd exposure occurred in patients with Cr levels of >3.0 mg/dL before DSA and in those receiving >0.4 mmol/kg of Gd. For patients who received iodinated contrast in combination with Gd, there was a trend toward a higher risk for developing ARF as compared with those receiving only Gd. Finally, there were no instances of NSF identified in any of the patients who received intra-arterial Gd. Conclusions: Although Gd has the potential to cause kidney injury similar to iodinated contrast, the risk of irreversible renal failure and the requirement for dialysis is low. Life- or limb-threatening interventions should not be avoided in this patient cohort because of preexisting elevations in Cr. These data should help guide the use of Gd in patients with chronic renal insufficiency.",
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